Immediate fever during anaesthesia recovery after surgical procedure with scoliosis: A case report and literature review

Abstract

Introduction and importance

Fever is a common clinical symptom in patients with postoperative scoliosis. However, there are rare reports of immediately fevers occurring following operative procedures.

Case presentation

A 15-year-old female with a 1-year history of scoliosis was admitted to the hospital after a health examination. The patient was diagnosed with idiopathic scoliosis and underwent a posterior idiopathic scoliosis procedure and correction for pedicle fixation. The clinical symptoms, including chills, fever, increased heart rate and increased blood pressure, were observed immediately following surgery during anaesthesia recovery. The patient was discharged from the hospital 12 days post-surgery. Over the 90-day follow-up, no chills, fever (≥38 °C), deep tissue infection, or surgery-related complications were reported. This remained consistent for the subsequent 3-year follow-up.

Clinical discussion

The patient was discharged 12 days after the operation, and no chills or fever (≥38 °C) occurred during the 90-day follow-up. Furthermore, there were no instances of deep tissue infection or any other surgery-related complications throughout the subsequent 3-year follow-up duration. A literature review has performed for this subject by systematic review. We identified only three reports that specifically examined postoperative fever as an observational measure among spine surgical patients. Unfortunately, none of these reports mentioned immediate postoperative fever.

Conclusion

Based on the available clinical data and research evidence, it is recommended to exercise caution when treating patients who experience postoperative chill and fever, as it may be caused by a combination of intraoperative hypothermia and anaesthesia inhibition. While these symptoms may be self-limiting in nature, close monitoring and appropriate management should be implemented to ensure patient safety and to identify any potential complications.

Highlights

• •Fever is a common clinical symptom in postoperative surgery patients. However, chills and fevers occurring immediately following surgery, which do not have a clear physiological mechanism.
• •Unless there is clear clinical evidence indicating a worsening trend, the significant observation is that immediately postoperative fevers are self-limiting and non-progressive.
• •Our review of prior cases demonstrates an overall rare for the rapid symptoms in scoliosis, the physiological mechanism of which is not yet understood.

1. Introduction

Postoperative fever is a common clinical symptom in patients following spinal surgery, with an incidence of 13.2 % [1], and 64.5 % of patients with neuromuscular scoliosis were observed to develop postoperative fevers [2]. The most frequently observed cause of fever is surgical trauma, which is associated with inflammatory responses to surgery, and such fevers typically resolve within 2–3 days [1,3]. This self-limited cause of postoperative fever is non-pathological [4], and the severity and duration of such fevers depend on the duration [1], scope [5], and type of surgery [[4], [5], [6]], and whether a mesh graft was inserted [1]. The aetiology of immediate postoperative fever for patients following hip prosthesis implantation is unknown, and it is inexpedient to initiate antibiotic treatment or to increase the prophylactic antibiotic dosage [7]. However, there are rare reports of chills and fevers occurring immediately following spinal surgery, to the best of our knowledge, there have been no reports on the mechanism of immediate postoperative fever following spinal surgery.

Based on this evidence and on observation, when patients experience postoperative fevers, nearly all surgeons seek to exclude infection as a cause [8]. The case presented in this paper is that of a 15-year-old female with idiopathic scoliosis who underwent posterior idiopathic scoliosis incision and correction for pedicle fixation. The clinical symptoms of interest, including chills, a high fever, an increased heart rate and increased blood pressure, were observed immediately during the course of anaesthesia resuscitation. In this report, risk factors, treatment and prevention are assessed based on the case evidence.

2. Case presentation

A 15-year-old female with a 1-year history of scoliosis was admitted to the hospital after a health examination. A radiograph of the patient's spine revealed progressive double thoracic scoliosis with a main right convex thoracic scoliosis from T2 to L1 of 50°, with its apex at T8, and a left convex upper thoracic scoliosis from T8 to S1 of 35° (Fig. 1A). There was no family history of spinal or chronic disease.

Fig. 1.

Preoperative X-ray plain films, surgical exposure, and orthopedics.

Preoperative patient preparation includes anaesthesia assessment, blood preparation and autologous blood recovery transfusion. The patient underwent a posterior idiopathic scoliosis procedure and correction for pedicle fixation under general anaesthesia (Fig. 1B). The anaesthesia protocol that sufentanil, etomidate, and midazolam represent suitable means to induce anaesthesia, and atracurium, propofol and fentanyl are used to maintain anaesthesia. Intraoperative bleeding amounted to approximately 1000 ml, the transfused quantity of allogeneic concentrated red blood cells was 1.5 μ (300 ml), and the autologous blood recovery transfusion totalled 750 ml. The surgery duration was 6.2 h, and the anaesthesia duration was 6.8 h. The intraoperative vital signs were stable, and the evoked potential spinal cord monitoring was normal (Fig. 2).

Fig. 2.

Intraoperative anaesthesia monitoring record.

The clinical symptoms of interest, including chills, fever, an increased heart rate and blood pressure, were observed immediately during anaesthesia resuscitation after surgical procedure (Fig. 2). The highest patient temperature reached 39.4 °C, the increased heart rate reached 146 beats per minute (91 beats per minute in preoperative), and the increased blood pressure reached 190/89 mm/Hg (125/78 mm/Hg in preoperative). The immediate intervention included 10 mg dexamethasone by intravenous injection, convective warming of the patient, and accelerated liquid infusion using the compound sodium chloride. The patient was then transferred to a recovery room for close monitoring and conservative management. The patient was escorted back to the ward at 2 h postoperatively (her temperature was 38.8 °C, her heart rate was 128 beats per minute, and her blood pressure was 140/62 mm/Hg) (timeline in Fig. 3), during which time the patient's vital signs were monitored, the patient began sweating at 3 h after the surgical procedure, followed by a subsequent decrease in body temperature to the normal level (Fig. 4).

Fig. 3.

Temperature and laboratory data during hospitalization.

Fig. 4.

Case timeline.

During the patient's recovery period in the ward, the postoperative recovery was smooth. Various interventions and treatments were provided, including antibiotics to prevent infection, hydration management, hormone therapy if needed, pain relief measures, care for the patient's stomach, and efforts to improve circulation. Additionally, dressing changes were performed as necessary to promote wound healing. A review of the spine's radiograph showed that the position of the internal fixator was good, and the scoliosis had significantly improved. Additionally, the laboratory tests came back clean, revealing no abnormal changes, further indicating a favorable outcome after the procedure (Fig. 4). The patient was discharged from the hospital 12 days after surgical procedure. During the 90-day follow-up period, no instances of chills or fever (defined as a temperature equal to or exceeding 38 °C) were reported, and there were no occurrences of deep tissue infection or other complications related to the surgery during the subsequent 3-year follow-up period.

The work has been reported in line with the SCARE criteria [9].

3. Discussion and conclusions

Immediate postoperative fever following scoliosis surgery is rarely reported in the literature, which focuses predominantly on infectious [10,11] and non-infectious [[4], [5], [6]] postoperative fevers 24 to 72 h after surgery. The risk factors, treatments, and prevention of immediate fevers in postoperative patients require analysis.

We conducted our search strategy according to the PICOS approach, which patients (no limitation), intervention (scoliosis or spinal surgery, general anaesthesia), comparison (no limitation), outcome (fever, heart rate, and mean blood pressure), and study (no limitation). A search of the database with PubMed MEDLINE, EMBASE Ovid and CENTRAL. We identified only three reports that specifically examined postoperative fever as an observational measure among spine surgical patients [2,12,13]. Unfortunately, none of these reports mentioned immediate postoperative fever, instead primarily focusing on haemodynamic indices such as heart rate, blood pressure, and cardiac index as their primary outcomes (Supplementary Appendix). To collect additional research evidence, we subsequently analysed the risk factors for and the treatment and prevention of postoperative fevers in non-scoliosis surgeries as reported in the literature.

Postoperative fever is represented by an increased body temperature higher than 38 °C and considered a common event that might complicate postoperative treatment [14]. Increasing evidence indicates that a postoperative fever is an inflammatory response to surgical trauma to tissue resulting from the release of cytokines, such as interleukins 1 and 6, tumour necrosis factor-α, and interferon-γ, which affect the thermoregulatory mechanism at the hypothalamus; nevertheless, infection is an uncommon cause of postoperative fevers following posterior spinal fusion [3,4]. However, despite these indicators, when patients develop postoperative fevers, nearly all surgeons seek to rule out the possibility of an infection [8]. The majority of fevers, particularly during the early postoperative period, are the result of non-infectious precipitants [8]. In this case, the clinical symptoms of chills and fevers appeared immediately after surgery procedure, and there was no evidence of a preoperative and postoperative bacterial infection from laboratory data. We ruled out the possibility of an acute intraoperative infection.

The duration of a surgery can have an impact on a patient's temperature and fever response. Prolonged surgeries, especially those lasting several hours, can lead to a greater degree of tissue trauma and inflammation [3]. Junghan Seo finds that postoperative non-pathological fevers can occur after 6.5 ± 3.01 days [1]. This evidence is not consistent with the case presented here.

Intraoperative autotransfusion should be evaluated with respect to its risks and benefits in individual cases [15]. In this case, 750 ml of blood was transfused by using an autologous blood recovery system, and there were no symptoms of haemolysis, haemoglobinuria and coagulation abnormalities following the transfusion. The inflammatory variable (WBC count) reflected no blood contamination [16]. Therefore, we do not consider that the immediate fever and chills observed in this case were caused by the blood transfusion.

Malignant hyperthermia (MH) does not have a clear physiological mechanism, although skeletal and muscle metabolic abnormalities and hypothyroidism are associated with anaesthesia. Considering human genetic susceptibility associated with how abnormal chromosomal genetics affect MH, anaesthesia is a factor that can cause skeletal muscle stiffness, high metabolism and high fever; if not immediately treated, tissue damage or death can occur [17,18]. The diagnosis of MH is mainly based on indicators such as hyperpyrexia (> 40 °C), hyper-lactic acid and PaCO₂ increases [18,19]. Arterial blood gas analyses results did not support the diagnosis of MH in the patient with clinical data.

The incidence of tachycardia and hypertension is more frequent with general than spinal anaesthesia [20,21]. Previous animal mechanism research on sheep found that small doses of endotoxins evoked a dramatic biphasic response of opioid peptide secretion into the blood [22]. The general anaesthesia is a risk factor that impacts haemodynamic stability in patients [20], with cytokines being the most important group of inflammatory mediators, as they regulate the alterations that are evident in haemodynamic, metabolic and immune responses [23]. Based on this evidence, we consider general anaesthesia to be a risk factor in the fluctuation of haemodynamic stability.

The core body temperature is normally tightly regulated at around 37 °C [24]. General anaesthesia greatly impairs thermoregulation and synchronously reduces the thresholds for vasoconstriction and shivering [25], which the effect of general anaesthesia on the inhibition of the thermoregulatory defence mechanism is dose dependent and can result in perioperative hypothermia [24,25]. When recovering from anaesthesia, which relates to temperature loss via inhibition of temperature regulation, patients experience shivering thermogenesis, their heart rates increase (thus increasing cardiac output), and they experience increased blood pressure, which may be caused by a postoperative shivering fever [[25], [26], [27]]. However, the hormonal intervention that was used was unsuccessful and did not represent a wise choice in this patient [[28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40]]. The patient's temperature gradually returned to normal as time passed, which the patient sweating 2 h after surgery procedure, and sustain normal until was discharged from the hospital. Therefore, it is reasonable to consider that a self-limiting process may have led to the postoperative fever, meaning patient resolve without any specific treatment.

In summary, based on the available clinical data and research evidence, it is recommended to exercise caution when treating patients who experience postoperative chill and fever, as it may be caused by a combination of intraoperative hypothermia and anaesthesia inhibition. While these symptoms may be self-limiting in nature, close monitoring and appropriate management should be implemented to ensure patient safety and to identify any potential complications.

List of abbreviations

T

Thoracic vertebra

PICOS

A framework used in research to help formulate research questions and identify key components of a study

RCTs

Randomized controlled trials

SVs

Decreased cardiac volumes

CIs

Cardiac indexes

IAT

Intraoperative autotransfusion

WBC

White blood cell

CSF

Cerebrospinal fluid

MH

Malignant hyperthermia

Consent for publication

Written informed consent was obtained from the patient to publish this case report and accompanying images.

Patient consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval for this study (Ethical Committee No. YJLW2019001) was provided by the Ethical Committee of Affiliated Hospital of Guangdong Medical University, Zhanjiang, China on 19 July 2019.

Funding

This study was funded by the Science and Technology Plan Project of Zhanjiang (No. LCYJ2019B008 and 2021A05073). The funding was using to collect case data, purchase full-text copies of the studied literature, analyse the features of postoperative chills and fever, and to pay for English language editing.

Guarantor

Yiyue Zhong.

Research registration number

• 1.Name of the registry: The ClinicalTrials.gov Protocol Registration and Results System (PRS)
• 2.Unique identifying number or registration ID: NCT06405659
• 3.Hyperlink to your specific registration (must be publicly accessible and will be checked): https://register.clinicaltrials.gov/prs/app/template/Home.vm?uid=U0006ZEX&ts=37&cx=-l8dioi.

CRediT authorship contribution statement

LMZ, XMC, MZM and YYZ developed the idea of the study, participated in its design and coordination, and helped draft the manuscript. LMZ and GXM contributed to the acquisition and interpretation of data. JSW provided a critical review and substantially revised the manuscript. All authors read and approved the final manuscript.

Declaration of competing interest

The authors declare no conflicts of interest related to this study.

Appendix A. Supplementary data

Supplementary material